RU2142740C1 - Surgical method for treating the cases of sollinger-ellison syndrome and stomach peptic ulcers in cardiac region - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves removing acid-producing stomach part. Selective proximal vagotomy is carried out. The resected stomach region is substituted with jejunum loop. End-to-loop esophagointestinal anastomosis is formed. Anastomosis is created on both ends of jejunum loop with innervated antral stomach region. EFFECT: improved functional results of treatment. 8 dwg

Description

 The present invention relates to medicine, namely to surgery, and can be used to treat Zollinger-Ellison syndrome and ulcers of the cardiac section of the stomach with the destruction of the cardiac sphincter.

 Ulcerogenic Zollinger-Ellison syndrome, described in 1955 (Zollinger R.M., Ellison E.N., 1955), is caused by tumor growth or hyperplasia of extragastric gastrin-producing G-cells that produce gastrin excessively and create a high concentration of it in the blood. Hypergastrinemia supports acid production in the stomach in a state of constant submaximal stimulation. Hyperproduction of hydrochloric acid leads to the formation of stomach ulcers, duodenum, and even jejunum, which persistently recur after traditional methods of surgical treatment (resection and resection of the stomach, vagotomy). Gastrinoma is detected in 0.1% of patients with duodenal ulcer and in 2 - 5% of patients with recurrent ulcer after surgical treatment. The source of hypergastrinemia can be multiple tumors in various organs of the abdominal cavity, hyperplasia of the pancreatic G-cells, therefore, during surgery, you can never be sure of detecting and eliminating all the causes of excess gastrin production. In this regard, with Zollinger-Ellison syndrome, gastrectomy is considered shown to remove the point of application (target) of gastrin. However, in modern conditions, with reliable criteria for the diagnosis of ulcerogenic syndrome, as well as the development of new organ-preserving methods for the surgical treatment of duodenal ulcers - SST and duodenoplasty, the problem of finding more gentle and functionally justified methods of surgical treatment of Zollinger-Ellison syndrome is relevant for surgical gastroenterology.

 The development of new methods for the surgical treatment of cardiac gastric ulcers also remains an urgent problem, since the only radical resection methods of treatment for this pathology (subtotal proximal and distal resection) often give unsatisfactory immediate and long-term results due to the high incidence of post gastroresection disorders (reflux gastritis, reflux esophagitis, dumping syndrome, etc.).

 An analogue of the proposed method in the treatment of Zollinger-Ellison syndrome is gastrectomy, which is performed to remove the point of application (target) of gastrin, i.e. It has the same purpose as the proposed method and is similar to it in essence and the achieved result. The technique for performing gastrectomy is well known and described in all surgical manuals, so it is necessary to dwell on the shortcomings of gastrectomy in relation to the treatment of Zollinger-Ellison syndrome, which make us suggest new methods of surgery for this syndrome.

 1. High frequency of early postoperative complications, leading to high mortality (on average, 15 - 18%).

2. Gastrectomy leads to the development of severe postoperative disorders, often leading to disability. These consequences include:
1) impaired appetite; 2) regurgitation syndrome; 3) reflux esophagitis; 4) dysphagia; 5) stool disorders; 6) dumping syndrome; 7) hematological changes - hypochromic and pernicious anemia; 8) weight loss; 9) neuropsychiatric disorders, etc.

 An analogue of the present invention in the treatment of ulcers of the cardiac section of the stomach is a resection of the cardial section of the stomach (E.N. Vantsyan, A.F. Chernousov, A.M. Korchak. Ulcer of the cardial section of the stomach. M .: Medicine. 1982. - P. 114 - 117). The stomach is mobilized along the lesser curvature with the isolation and ligation of the trunk and branches of the left gastric artery, then, taking away the branches of the vagus nerve, as is done with selective vagotomy, the abdominal esophagus is additionally mobilized. The line of intersection of the stomach runs from the pylorus along the lesser curvature to the lower pole of the spleen along the greater curvature. For an anastomosis with the esophagus, using the UKL-60 apparatus, a gastric tube is formed from large curvature, followed by covering the brackets with serous-muscular sutures. Two silk holders are placed on the sides of the esophagus, about 3-4 cm above the estimated line of its resection, cross it, and part of the stomach with the ulcer is removed. After this, an invagination esophageal-gastric anastomosis is formed according to Tsatsanidi.

The disadvantages of the analogue are:
1. The real danger of failure of esophago-gastroanastomosis.

 2. Destruction of the innervation of the antrum and pyloric sphincter, which leads to functional impairment of the coordinated work of the gastro-duodeno-pancreatic-biliary complex.

 3. High likelihood of developing reflux esophagitis due to loss of cardiac valvular apparatus.

 4. Perhaps the development of the syndrome of the "small stomach" due to a decrease in the gastric reservoir.

 The prototype of the present invention is a method of treating Zollinger-Ellison syndrome by resection of the acid-producing section of the stomach, proposed by V. D. Sidorenko and N. V. Voronov (A. S. N 1277956 of September 22, 1983). At the same time, a gastrotomy is performed, the gastric mucosa is washed with a soda solution, drained and irrigated with a solution of Congo red. In this case, the border between the mucous membrane of the stomach’s body is black-gray and the antrum, which retains a pink color, is clearly revealed. The border of the acid-producing zone of the stomach is indicated by holders on the serous membrane of the stomach. The proximal part of the stomach is resected at the designated boundaries. An esophageal-gastric invagination anastomosis is formed end to side.

This method contains the most important feature that is identical to the features of the claimed object, namely, the complete removal of the acid-producing zone of the stomach after marking its borders while maintaining the antrum, pylorus, esophago-gastro-duodenal continuity. All this contributes to better compensation of digestion in the long term. However, the prototype has the following disadvantages:
1) there is a real danger of failure of esophago-gastroanastomosis;
2) the innervation of the antrum is not preserved, which worsens the functional results of the operation;
3) the development of the syndrome of the "small stomach" due to a significant decrease in the gastric reservoir;
4) the development of reflux esophagitis is possible.

 In the proposed method, these disadvantages are eliminated by maintaining antral innervation and the formation of areflux pulp end-loop esophago-ejunoanastomosis with the replacement of the stomach with a loop of the small intestine.

 The purpose of the invention: improving the immediate and long-term functional results of surgical treatment of patients with Zollinger-Ellison syndrome and ulcers of the cardiac section of the stomach, improving the quality of life of patients after surgery.

 Tasks: 1. To develop a method of operation, providing for the complete removal of the acid-producing department of the stomach while preserving the innervated antrum and the pyloric sphincter.

 2. To develop a method for plastic replacement of the body of the stomach and cardiac closure apparatus (esophageal-cardiac sphincter) with an enteric transplant.

 The essence of the proposed method is the implementation of SST and resection of the acid-producing section of the stomach (after preliminary determination of its distal border) while maintaining the innervation of the antrum and pylorus with the subsequent replacement of the body of the stomach with a loop of the small intestine by applying an end-loop areflux esophageal-intestinal and terminal-terminal (two ends intestinal loop at the end of the antrum) of the gastrointestinal anastomoses. If there is a duodenal ulcer, the method is supplemented by duodenoplasty. With Zollinger-Ellison syndrome, the method, if possible, is combined with the removal of a gastrin-producing tumor.

 The method is as follows.

 The first stage of the intervention is the radical removal of the gastrin-producing tumor, if possible. To detect it, a visual and palpation examination of the pancreas, duodenum, stomach, and liver is performed. The last stage of intraoperative diagnosis is intraoperative ultrasound, which allows to detect small nodes in the pancreas and metastases in the liver. After determining the location of the tumor, it is husked out of the pancreatic tissue, or a pancreas is resected with the tumor. Then proceed to antacid surgery. Mobilization of the stomach is performed along a large curvature from the border of the antrum to the esophagus, with the intersection of the gastric branches aa. gastroepyploicae dextra et sinistra, a.gastroepyploica sin. trunk, short arteries of the stomach. The border of the antrum is determined and marked during preoperative endoscopic examination by staining the gastric mucosa with Congo-red and injecting into the submucosal layer at the border of the antrum and the body of Chinese carcass.

 After mobilization of the stomach along the greater curvature, the abdominal part of the esophagus, cardia and lesser curvature are mobilized according to the type of selective proximal vagotomy (SPV), with preservation of both main gastric nerves and innervation of the antrum and pylorus. The distal border of mobilization is the “goose paw” of the Laterger nerve, which usually corresponds to the true border between the antrum and the acid-producing zone of the stomach. The acid-producing zone of the stomach is resected: the proximal resection line runs along the border of the esophagus and cardia, and the distal one corresponds to the border of the antrum and body of the stomach, defined and marked endoscopically and taking into account the conservation of the innervation of the antrum and pylorus, i.e. "paws" of both Latheré nerves (Fig. 1).

 The reconstructive stage of the operation begins with narrowing of the esophageal opening of the diaphragm to the diameter of the esophagus by stitching the diaphragmatic legs with interrupted sutures. The walls of the esophagus are fixed with 4 sutures to the edges of the diaphragm. Thus, around the stump of the esophagus, above the proposed anastomosis, muscle pulp is created from the legs of the diaphragm and the esophagus is prevented from moving up. In the mesentery of the transverse colon, a wide transverse window is made through which a loop of the jejunum is passed to the upper floor of the abdominal cavity (Fig. 2). The displaced loop of the small intestine behind its mesentery is fixed with 2 U-shaped sutures to the legs of the diaphragm and the capsule of the pancreas. In the mesentery of the jejunum loop, between its straight vessels, at the level of 2 or 3 mesenteric artery, a window is made corresponding to the diameter of the esophagus. Then the loop of the jejunum through the window in its mesentery is put on the esophagus (Fig. 3). The edges of the mesentery window of the jejunum are fixed by the ends of 4 U-shaped sutures, which previously sewn the wall of the esophagus to the diaphragm (Fig. 3, a). If the gap between the vessels is narrow and it is difficult to grasp the edge of the mesenteric window into the suture, then the lateral U-shaped sutures are best applied to adjacent intervascular spaces. After putting on the loop of the jejunum on the stump of the esophagus and fixing the edge of the mesenteric window to the diaphragm and esophagus, the wall of the intestine fits freely, evenly and widely against the wall of the esophagus, covering it with the inside of the loop for 3.5 - 4 cm. Widely and correctly matched by wrapping method the walls of the intestine and esophagus are adapted by 3 rows of sutures. In the first row, consisting of 4-6 nodal sutures, the esophagus, intestine and mesentery of the intestine are involved so that its peritoneum is more closely adjacent to the walls of the esophagus (Fig. 4, a). In the seam should be taken through its muscle layers of the esophagus wall obliquely, the mesentery for its peritoneal sheet, just at the transition to the intestine, and the intestine for its serous-muscular layer at the mesentery itself. These sutures are superimposed between the entry of direct vessels into the intestinal wall, where they are clearly visible and not damaged. Both knees of the bowel loop are sewn with such sutures (Fig. 4, b). 1.5 - 2 cm above this row of seams is another row of nodal joints. Retreating another 1 cm from the suture line, the muscle layer to the submucosa is dissected on the esophagus, and the distal muscle cuff without violence is shifted upward by 1.5 cm with a tuffer (Fig. 5, a). On the loop of the intestine, also retreating 1 cm from the suture line, the submucosal layer is widely exposed (Fig. 5, b). Closely adjacent to each other submucosal esophagus and intestines are adapted by precision serous-muscular-submucosal monolithic sutures (Fig. 5. c). The stump of the esophagus is cut off along the edge of the upper muscle roller, and a loop of the intestine is opened along the edge of the peripheral serous-muscular roller, which creates an excess of mucous membranes of the esophagus and intestine. Under the action of the underlying suture, in which the submucosal layer is included, the mucous membranes are tightly in contact with their submucosal, forming a smooth bead. If the submucosal layer of the intestine is barely exposed, then a sero-muscular-submucosal suture with nodal catgut or kapron sutures should be performed. In this case, the serous membrane of the intestine carefully adapts with the submucosal layer of the esophagus. Then the gaps of the stitched organs are opened, and their edges are adapted by interrupted sutures only in bleeding segments. In this case, the suture penetrates through the mucous-submucosal layer of the esophagus and through all layers of the intestinal wall. The external edges of the intestinal wound are sutured with a serous-muscular-submucosal suture (Fig. 6). The marginal suture is reinforced with another series of sero-muscular sutures. T. about. , the formation of the esophageal-intestinal anastomosis ends with the formation of a reservoir above it of the intestinal arched anastomosis.

 After the formation of the end-loop esophageal-intestinal anastomosis, the leading and outlet sections of the intestinal loop intersect at a distance sufficient to overlap the end-terminal (two ends into one) gastrointestinal anastomosis (Fig. 7) and the ends of the loop are brought together in the form of a double-barreled shotgun by applying separate serous-muscle sutures (Fig. 7, a). Adjacent to each other, the walls of the leading and outlet ends of the loop are sewn together along the section plane with several (3 - 4) serous-muscular-submucosal sutures (Fig. 7, b). Both ends of the double-barreled shotgun thus formed (Fig. 8, a) anastomose with the antrum of the stomach (Fig. 8, b). Anastomosis is formed by a single-row precision serous-muscular-submucosal suture with monofilament 4/0 - 6/0. The continuity of the small intestine is restored by inter-intestinal anastomosis end to end (Fig. 8, c).

 Thus, as a result, the resected acid-producing zone of the stomach is replaced by a loop of the jejunum, due to which a reservoir is created. The end-loop esophageal-intestinal anastomosis is reliable, has pronounced areflux valve properties, replacing lost cardia, which prevents the development of reflux esophagitis. Preservation of the vagal innervation of the antrum of the stomach and pyloric sphincter, as well as the extra-gastric parasympathetic innervation of the abdominal organs, contributes to the rapid restoration of self-regulation of the functions of the gastro-duodeno-pancreatic-biliary complex and the adaptation of the digestive system to new conditions. All this contributes to good clinical and functional results of the operation.

 The method was tested on 3 patients with Zollinger-Ellison syndrome and 6 patients with an ulcer of the cardiac section of the stomach with a transition to the esophagus.

 1. Patient B., 41, was admitted to the clinic on September 16, 93 with complaints of severe pain in the epigastrium and left hypochondrium on an empty stomach, pain and burning behind the sternum, periodic diarrhea. Suffers from duodenal ulcer since 1990, in December 1991, a segmental duodenoplasty was performed at the clinic for decompensated stenosis of the duodenal bulb. Intraoperatively - “kissing” ulcers of the duodenal bulb, posterior - large, with deep penetration into the pancreas. In the first month after the operation, the condition worsened, nausea, heartburn, periodic vomiting and diarrhea bothered. After the spa treatment, there was no improvement. In March 1992, she was admitted to the clinic with a picture of gastrointestinal bleeding. With FGDS, a recurrent duodenal ulcer of large sizes with a thrombus at the bottom without signs of ongoing bleeding was detected. Conducted conservative therapy, after which the patient was examined. With FGDS, erosive reflux esophagitis, erosive gastritis, thickening of the folds of the gastric mucosa, recurrent ulcer of the posterior wall of the duodenum 1.5 cm in diameter, 5 mm deep, its lower edge 5 mm from the BDS, the pylorus is completely closed. With a fluoroscopy of the stomach, the relief of the mucous membrane is rough, the folds are sharply thickened, on an empty stomach - a large amount of fluid. The initial section of the duodenum is deformed, there is a stenosis of 2–3 degrees, on the back wall there is a deep ulcerative niche, the pylorus is functioning. The study of the secretory function of the stomach - BOD 44.7 mmol / h, MIC (on pentagastrin) 71.8 mmol / h. BOD / IPC - 62%. Calcium test: against the background of intravenous infusion of calcium gluconate, HCl secretion in the 1st hour is 64.3 mmol, in the 2nd hour - 82.4 mmol. Ultrasound revealed a focal formation in the body of a round pancreas with a diameter of up to 25 mm, as well as 2 focal formations in the head of the pancreas with a diameter of 8 and 15 mm. The diagnosis was established: Zollinger-Ellison syndrome, multiple pancreatic gastroinomas, recurrent duodenal ulcer, complicated by bleeding and stenosis of 2 - 3 tbsp., Erosive gastritis. Erosive reflux esophagitis. Before the operation, endoscopic marking of the boundaries of the antrum was performed. April 21, 1993 - operation. Laparotomy Performed segmental reduodenoplasty with preservation of the pylorus and leaving a crater of penetrating ulcers on the pancreas. The abdominal part of the esophagus and the lesser curvature of the stomach along the distal paw of the Latheré nerve were mobilized, the bottom and the greater curvature parietally mobilized to the border of the antrum marked with mascara. The esophagus was crossed 1 cm proximal to the esophagus-gastric junction, the distal stomach was crossed along the border of the body and antrum, preserving the “paws” of both Lather’s nerves, and the resected part was removed. An audit of the pancreas revealed a tumor node about 3 cm in diameter in the body, as well as several smaller nodules in the head of the pancreas. The tumor node in the head of the pancreas is husked and removed. Through the window in the mesentery of the transverse colon, a loop of the jejunum is drawn, an esophageal-intestinal end-loop anastomosis is formed. Both ends of the intestinal loop are crossed, stitched in the form of a double-barreled barrel and anastomosed with the antrum of the stomach. The continuity of the small intestine restored anastomosis end to end. The abdominal cavity is drained, a probe is inserted into the antrum. The postoperative period was uneventful, intestinal motility recovered on the 3rd day, enteral tube feeding was started on the 5th day, the probe was removed on the 9th day, and on the 10th day. - Nutrition through the mouth. Discharged 12 days after surgery. Examined after 3 months, 1 and 1.5 years after surgery. He feels satisfactory, complains of periodic severity in epigastrium and belching, and does not follow a diet. Endoscopically there are no signs of reflux esophagitis, the esophageal-intestinal anastomosis is closed in the form of a socket, then there is a small reservoir that goes into 2 channels (intestinal loops). The antrum actively peristals, the pylorus closes, the duodenal bulb is practically absent, the BDS is 1.5 cm from the pylorus. Mild duodeno-gastric reflux is noted.

 Patient D-ko, 57 years old, was admitted to the RCCH on September 16, 94 with complaints of pain in the left hypochondrium, heartburn, especially in a horizontal position. 7 months back was diagnosed with an ulcer of the cardiac section of the stomach, histologically - benign. It was treated conservatively with a temporary improvement, then the symptoms of the disease resumed and became more pronounced. FGDS: an ulcer of the cardiac section of the stomach measuring 2.5 by 1.5 cm, 0.5 cm deep with a pronounced inflammatory shaft around, the upper edge of which passes to the abdominal part of the esophagus. The cardia does not close, in the lower third of the esophagus - pronounced phenomena of erosive esophagitis. The doorkeeper closes completely, the duodenum bulb and the post-bulbar departments without features. PIP is a chronic stomach ulcer. The study of gastric secretion: OGF 40 ml, BOD 1.4 mmol / h, BMD 16.7 mmol / h. September 24, 1994 was operated. Upper midline laparotomy with hardware access correction RSK-10. During the audit, ulcerative infiltrate was found in the cardial part of the stomach along the lesser curvature with transition to the abdominal part of the esophagus, and distally reaching the middle third of the lesser curvature. A parietal mobilization of the abdominal esophagus type, small curvature of the stomach to the distal paws of the Laterger nerve, was performed along the type of PCV, the fundus of the stomach was parietally mobilized, and the great curvature to the border between the body and antrum. The esophagus is crossed at the proximal edge of the ulcerative infiltrate, distally - the stomach is crossed at the border of the antrum and body. A loop of the jejunum was drawn into the upper floor of the abdominal cavity and an end-loop esophageal-intestinal anastomosis was applied, and both ends of the crossed intestinal loop were anastomosed with the antrum. The continuity of the small intestine restored anastomosis end to end. A nasogastric tube was performed in the antrum. Layered seams on the wound. The postoperative period was complicated by pneumonia with left-sided exudative pleurisy, which resolved on the 18th day against the background of intensive antibacterial therapy. The probe was removed on the 7th day, began to eat on the 10th day. Examined after 6 months. and 1 year. No complaints, no diet. With FGDS, the mucosa of the esophagus is not changed, the esophageal-intestinal anastomosis - in the form of a closed outlet. According to a study of gastric secretion - achlorhydria.

 Using the method allows you to reliably suppress gastric secretion in Zollinger-Ellison syndrome and with a high degree of reliability to prevent the recurrence of peptic ulcers after surgery. With ulcers of the cardiac section of the stomach with the destruction of the cardiac sphincter, the method allows to radically eliminate the ulcer and prevent its recurrence. During this operation, the development of reflux esophagitis is prevented by creating a valve esophageal-intestinal anastomosis and a gastric reservoir is created, and the preservation of the innervated antrum and pylorus minimizes the likelihood of developing postoperative syndromes and creates optimal conditions for postoperative adaptation of the digestive system. Thus, the application of the method leads to the cure, or, if radical tumor removal is not possible, to a persistent improvement in the condition of patients with Zollinger-Ellison syndrome, and a reliable recovery of patients with an ulcer of the cardiac section of the stomach, returning them to normal life and work, provides them with high quality of life.

Claims (1)

 A method for the surgical treatment of Zollinger-Ellison syndrome and ulcers of the cardiac section of the stomach, including resection of the acid-producing section of the stomach, characterized in that they perform selective proximal vagotomy, plastic replacement of the resected proximal acid-producing section of the stomach with a jejunum loop with the formation of an end-loop esophageal and gastrointestinal anastomosis both ends of the loop of the jejunum with an innervated antrum.

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